If you are diagnosed with Obstructive Sleep Apnea, see the coverage criteria for Positive Airway Pressure Devices below.

Various tests may need to be performed to establish one of the above diagnosis groups.

Three months after starting your therapy you must return to your doctor or healthcare provider for a follow-up to confirm the machine is benefitting you and that you are regularly using the device.

This must be documented in your doctor or healthcare provider’s notes from that office visit. Your physician or healthcare provider will be required to respond in writing to questions regarding your continued use along with how well the machine is treating your condition.

If you are not using your machine for an average of four hours per night per 24 hour period at the time you meet with your doctor or healthcare provider, then you may be held responsible (via an Advance Beneficiary Notice) to pay for the rental until you meet this requirement.

BiLevel Devices are considered to be capped rental items, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.

Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.

Breast Prostheses

Breast Prostheses are covered after a radical mastectomy. Medicare will cover:

One silicone prosthesis every two years or a mastectomy form every six months.

As an alternative, Medicare can cover a nipple prosthesis every three months.

Mastectomy bras are covered as needed.

There is no coverage for replacement prostheses due to wear and tear before the specified time frames. However, Medicare will cover replacement of these items due to:

Loss

Irreparable damage, or

Change in medical condition (e.g. significant weight gain/loss)

You are allowed only one prosthesis per affected side, others will be denied as not medically necessary even if attempting asymmetry (an Advance Beneficiary Notice should be provided in this circumstance).

Mastectomy sleeves which are used to control swelling are not covered in the home setting because they do not meet Medicare’s definition of a prosthesis; however, it is possible that they may be covered under the hospital per diem if you request one during your hospital stay.

A mastectomy bra is covered if the pocket of the bra is used to hold a covered prosthesis or mastectomy form.

Cervical Traction

Cervical traction devices are covered only if both of the criteria below are met:

You have a musculoskeletal or neurologic impairment requiring traction equipment.

The appropriate use of a home cervical traction device has been demonstrated to you and you are able to tolerate the selected device.

Commodes**

A commode is only covered when you are physically incapable of utilizing regular toilet facilities. For example:

You are confined to a single room, or

You are confined to one level of the home environment and there is no toilet on that level, or

You are confined to the home and there are no toilet facilities in the home.

Heavy-duty commodes are covered if you weigh over 300 pounds.

Commodes with detachable arms are covered if your body configuration requires extra width, or if the arms are needed to transfer in and out of the chair.

** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.

Compression Stockings

Gradient compression stockings worn below the knee are covered only when used for the treatment of open venous stasis ulcers. They are not covered for the prevention of ulcers, prevention of the reoccurrence of ulcers, or treatment of lymphedema or swelling without ulcers.

Continuous Positive Airway Pressure (CPAP) Devices are covered only if you have Obstructive Sleep Apnea (OSA).

Medicare requires that you first meet with your physician or healthcare provider to discuss your symptoms and risk factors for Obstructive Sleep Apnea.

After meeting with your doctor or healthcare provider, you must then have an overnight sleep study performed in a sleep laboratory or through a special, in-home sleep test to establish a qualifying diagnosis of Obstructive Sleep Apnea.

Your doctor or healthcare provider may then prescribe a CPAP to treat your obstructive sleep apnea. Medicare will initially cover a three month trial of this equipment. Medicare will also pay for replacement masks, tubing and other necessary supplies as prescribed by your doctor or healthcare provider.

If during your sleep study (or during your trial period) the CPAP device is not working for you, or if you cannot tolerate the CPAP machine, your doctor or healthcare provider may prescribe a different device called a Bi-Level or a Respiratory Assist Device, and Medicare can consider this for coverage as well.

After the first three months of use, you will be required to verify if you are benefiting from using the device and how many hours a day you are using the machine. Per Medicare, a follow-up face-to-face visit with your physician or healthcare provider is required to document an improvement of your symptoms no sooner than 31 days and no later than 91 days from the set-up date. Data is typically downloaded from your sleep equipment and must be provided to your doctor or healthcare provider during this follow-up visit to document that the machine has been used consistently for at least 4 hours per night on 70% of nights during a 30-day consecutive period.

Talk with your supplier if you are having problems adjusting to the therapy or using the equipment every night. There are a lot of variations that can make the therapy more comfortable for you.

CPAPs and Bi-Levels are considered capped rental items, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.

Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.

Medicare does not cover insulin injections or diabetic pills unless covered through a Medicare Part D benefit plan.

Diabetics can obtain up to a three month supply of testing materials at a time.

Medicare will approve up to one test per day for non-insulin dependent diabetics and three tests per day for insulin-dependent diabetics without additional verification of need.

If you test above these guidelines, you are required to be seen and evaluated by your physician or healthcare provider within six months prior to receiving your initial supplies from your supplier.

In addition, you must send your supplier evidence of compliant testing (e.g. a testing log or notes from your physician) every six months to continue getting refills at the higher levels.

If at any time your testing frequency changes, your physician or healthcare provider will need to give your supplier a new prescription.

As of July of 2013, Medicare began a national mail order program that requires you to get your diabetic supplies through one of approximately 20, nationally contracted suppliers for all testing supplies delivered to your home.

Your supplier may not be able to deliver your glucometer to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.

Glasses

Medicare covers one complete pair of glasses, after the last cataract surgery with intra-ocular lens replacement. The Medicare benefit includes a frame and two lenses. As an alternative a pair of contact lenses can be covered in lieu of glasses.

Medicare beneficiaries that have a condition called aphakia (patients who born without an intra-ocular lens, or who have had the lens removed and not replaced), Medicare will cover glasses, and/or contacts as often as is medically necessary.

A hospital bed is covered if you have visited your doctor or healthcare provider and during an office visit your doctor or healthcare provider documents in your chart that one or more of the following criteria (1-4) are met:

You have a medical condition which requires positioning of the body in ways not feasible with an ordinary bed (elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed), or

You require positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or

You require the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out, or

You require traction equipment which can only be attached to a hospital bed.

Specialty beds that allow the height of the bed to be adjusted are covered if you require this feature to permit transfers to a chair, wheelchair or standing position.

A semi-electric bed is covered if your medical condition requires frequent changes in body position and/or you have an immediate need for a change in body position.

Heavy-duty/extra-wide beds can be covered if you weigh over 350 pounds.

The total electric bed is not covered because it is considered a convenience feature. If you prefer to have the total electric feature, your supplier usually can apply the cost of the qualifying hospital bed toward the monthly rental price of the total electric model. You will need to sign an Advance Beneficiary Notice (ABN) and will be responsible to pay the difference in the retail charges between the two items every month.

Hospital beds are a capped rental item, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.

Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.

Lymphedema Pumps

Lymphedema Pumps are covered for treatment of true lymphedema as a result of:

Primary Lymphedema resulting from a congenital abnormality of lymphatic drainage or Milroy’s disease. (This is a relatively uncommon, chronic condition), or

Secondary lymphedema is much more common and results from the destruction of or damage to formerly functioning lymphatic channels such as:

Before you can be prescribed a pump, your physician or healthcare provider must monitor you during a minimum, four-week trial period where other treatment options must be tried including limb elevation, exercise and compression garments or bandage systems. If, at the end of the trial, there is little or no improvement from these options, a lymphedema pump can be considered.

The doctor or healthcare provider must then document an initial treatment with a pump and establish that the treatment can be tolerated.

Lymphedema pumps also are covered for the treatment of chronic venous insufficiency (CVI) with venous stasis ulcers in the lower extremities (e.g. legs and feet).

Before you can be prescribed a pump for this condition, your physician or healthcare provider must monitor you during a minimum, six month trial period where other treatment options are tried such as limb elevation, exercise and compression garments or bandage systems. If at the end of the trial, one or more of the stasis ulcers are still present, a lymphedema pump can be considered.

The doctor or healthcare provider must then document an initial treatment with a pump and establish that the treatment can be tolerated, that there is a caregiver available to assist with the treatment in the home, and then the doctor or healthcare provider must prescribe the pressures, frequency, and duration of prescribed use.

Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

Medicare-covered drugs (other than Medicare Part D coverage)

As of February 2001, all suppliers of Medicare-covered drugs are required to accept assignment on these items.

Traditional Medicare Part B insurance will cover some nebulizer drugs, some infused drugs that require the use of a pump, specific immunosuppressive drugs, select oral anti-cancer medications and most parenteral nutrition.

The Medicare Part D plans may provide additional coverage of other oral medications, inhalers and similar drugs.

Mobility Products: Canes, Walkers, Wheelchairs, and Scooters**

Essentially the Medicare policy on mobility products requires that Medicare funds are only used to pay for:

Medicare requires that your physician or healthcare provider and supplier evaluate your needs and expected use of the mobility product to determine which item you will qualify for.

They must determine which is the least level of equipment needed to help you be mobile within your home to accomplish daily activities by asking the following questions:

Will a cane or crutches allow you to perform these activities in the home?

If not, will a walker allow you to accomplish these activities in the home?

If not, is there any type of manual wheelchair that will allow you to accomplish these activities in the home?

If not, will a scooter allow you to accomplish these activities in the home?

If not, will a power chair allow you to accomplish these activities in the home?

Keep in mind if you have another higher level product in mind that will allow you to do more beyond the confines of the home setting, you can discuss with your supplier the option to upgrade to a higher level or more comfortable product by paying an additional out of pocket fee using the Advance Beneficiary Notice (ABN).

Your home must be evaluated to ensure it will accommodate the use of any mobility product.

A face-to-face examination with your physician or healthcare provider to specifically discuss your mobility limitations and need for powered mobility is required prior to the initial setup of a power chair, scooter or manual wheelchair.

In some cases for power mobility items you may also be asked to see a physical therapist or occupational therapist to determine the best fit and equipment selection.

The majority of all manual and power wheelchairs are considered capped rental items, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.

Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.

Nebulizers**

Nebulizer machines, medications and related accessories are usually covered if you have obstructive pulmonary disease, but can also be covered to deliver specific medications if you have HIV, Cystic Fibrosis, bronchiectasis, pneumocystosis, complications of organ transplants, or for persistent thick or tenacious pulmonary secretions.

You may obtain up to a three month’s supply of nebulizer medications and accessories at a time as long as you continue to regularly use the medications through your machine.

If at any time you stop using your medications, please notify your supplier.

Nebulizer machines are considered to be capped rental items, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.

Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.

Non-covered items (partial listing):

Adult diapers

Bathroom safety equipment

Hearing aides

Syringes/needles

Van lifts or ramps

Exercise equipment

Humidifiers/Air Purifiers

Raised toilet seats

Massage devices

Stair lifts

Emergency communicators

Low vision aides

Grab bars

Elastic garments

Orthopedic Shoes

Orthopedic shoes are covered when it is necessary to attach the shoe(s) to a leg brace.

Medicare will only pay for the shoe(s) attached to the leg brace(s).

Medicare will not pay for matching shoes or for shoes that are needed for purposes other than for diabetes or leg braces.

Ostomy Supplies

Ostomy supplies are covered for people with a:

colostomy,

ileostomy, or

urostomy

You may obtain up to a three month’s supply of wafers, pouches, paste and other necessary items as needed.

Oxygen**

Your doctor or healthcare provider must start with an office visit to discuss your symptoms before ordering any testing. If your symptoms are indicative of a chronic lung condition or other disease that requires long term oxygen therapy, Medicare will likely cover oxygen when the test results meet the coverage criteria outlined below.

Oxygen is covered if you have significant hypoxemia in a chronic stable state when:

You have a severe lung disease or hypoxemia that might be expected to improve with oxygen therapy, and

Your oxygen study was performed by a physician, qualified lab, other qualified provider and

Alternative treatments have been tried or deemed clinically ineffective.

Categories/Groups of oxygen therapy are based on the test results to measure your oxygen. There are two types of tests that can be used for this purpose. An Arterial Blood Gas (ABG) test is an invasive procedure which provides detailed information and a direct measurement of oxygen in arterial blood (from an artery). ABG test results are reported in millimeters of mercury (mmHg). A saturation test (SAT) is a non-invasive procedure that indirectly measures oxygen saturation using a sensor typically placed on the ear or finger. SAT test results are reported in percentages (%).

Group I Criteria: mmHG = 55, or saturation = 88%

For these results you must return to your physician or healthcare provider between 9-12 months after the initial visit to discuss whether your oxygen therapy should continue for lifetime or for a shorter period if the need is expected to end. Typically, you will not have to be retested when you return to your physician or healthcare provider for the follow-up visit.

Group II Criteria: 56-59 mmHg, or 89% saturation

For these results, you must return for another office visit with your physician or healthcare provider to discuss your oxygen therapy and for these borderline results you will also have to be retested within 3 months of the first test to continue therapy for lifetime or until the need is expected to end

Group III Criteria: mmHg = 60 or saturation = 90% is considered to be not medically necessary.

Note on nocturnal oxygen therapy: If you only require the use of oxygen during the nighttime, your doctor should rule out obstructive sleep apnea as a cause for the hypoxemia symptoms you may be experiencing. If obstructive sleep apnea is a potential factor, Medicare will not cover oxygen therapy until you have officially had the sleep apnea diagnosed and treated. When obstructive sleep apnea is a factor, testing for oxygen needs can only begin after the apneas are controlled with appropriate positive airway therapy using a CPAP or Bi-PAP.

Oxygen will be paid as a rental for the first 36 months. After that time, if you still need the equipment, Medicare will no longer make rental payments on the equipment. However, if equipment is still necessary, your supplier will continue to provide the equipment to you for an additional 24 months. During this two year service period, Medicare will pay your supplier for refilling your oxygen cylinders and for a semi-annual maintenance fee.

After 60 months of service through Medicare you may choose to receive new equipment.

Depending on which product is ordered, your supplier may not be able deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.

Patient Lifts**

A lift is covered if transfer between a bed and a chair, wheelchair, or commode requires the assistance of more than one person and, if without the use of a lift, you would be bed confined.

An electric lift mechanism is not covered; because it is considered a convenience feature. If you prefer to have the electric mechanism, your supplier can usually apply the cost of the manual lift toward the purchase price of the electric model. You will need to sign an Advance Beneficiary Notice (ABN) and would be responsible to pay the difference in the retail charges between the two items on a monthly basis.

Patient lifts are considered to be capped rental items, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.

Your supplier cannot deliver this product to you without a written order from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.

Seat Lift Mechanisms**

In order for Medicare to pay for a seat lift mechanism, you must be suffering from severe arthritis of the hip or knee, or have a severe neuromuscular disease. In addition you must be completely incapable of standing up from any chair, but once standing can walk either independently or with the aid of a walker or cane. The physician or healthcare provider must believe that the mechanism will improve, slow down or stop the deterioration of your condition.

Transferring directly into a wheelchair will prevent Medicare from paying for the device.

Medicare will only pay for the lift mechanism portion. The chair portion of the package is not covered, and you will be responsible for paying the full amount for the furniture component of the chair.

Your supplier cannot deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

New established requirements by the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a detailed written prescription.

** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.

Support Surfaces**

Group 1 products are designed to be placed on top of a standard hospital bed or home mattresses. They can utilize gel, foam, water or air, and are covered if you are:

Completely immobile OR

Have limited mobility or any stage ulcer on the trunk or pelvis (and one of the following):

impaired nutritional status

fecal or urinary incontinence

altered sensory perception

compromised circulatory status

Group 2 products take many forms, but are typically powered pressure reducing mattresses or overlays. They are covered if you have one of three conditions:

Multiple stage II ulcers on the pelvis or trunk while on a comprehensive treatment program for at least a month using a Group 1 product, and at the close of that month, the ulcers worsened or remained the same. (Monthly follow-up is required by a clinician to ensure that the treatment program is modified and followed. This product is only covered while ulcers are still present.) OR

Large or multiple Stage III or IV ulcers on the trunk or pelvis (Monthly follow-up is required by a clinician to ensure that the treatment program is modified and followed. This product is only covered while ulcers are still present.) OR

A recent myocutaneous flap or skin graft for an ulcer on the trunk or pelvis within the last 60 days where you were immediately placed on Group 2 or 3 support surface prior to discharge from the hospital and you have been discharged within the last 30 days.

A physician or healthcare provider must make monthly assessments as to whether continued use of the equipment is required. Sometimes your physician or healthcare provider may order a home healthcare nurse to come visit you to make these assessments.

Medicare will only pay for the rental of a Group 2 product until your ulcers completely heal. If your ulcers have healed you must return the equipment to your supplier or make arrangements to pay for future monthly rentals privately using an Advance Beneficiary Notice (ABN).

Group 3 products are air-fluidized beds and are only covered if you meet ALL of the following conditions:

A stage III or stage IV pressure ulcer, and

Are bedridden or chair bound as the result of limited mobility, and

In the absence of an air-fluidized bed would require institutionalization, and

An alternate course of conservative treatment has been tried for at least one month without improvement of the wound, and

All other alternative equipment has been considered and ruled out.

A physician or healthcare provider must assess and evaluate you after completion of a course of conservative therapy within one month prior to ordering the Group 3 support surface.

A trained adult caregiver must be available to assist you. Medicare does not cover the cost of hiring a caregiver, or for structural modifications to your home to accommodate this equipment.

Your supplier cannot deliver these products to you without a written order from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.

TENS Units**

TENS units are covered for the treatment of chronic intractable pain that has been present for at least three months or more, and in some cases for acute post-operative pain.

Not all types of pain can be treated with a TENS unit. TENS units have been proven ineffective in treating headaches, visceral abdominal pain, pelvic pain, TMJ pain, and most recently lower back pain. Therefore Medicare will not pay for the device or supplies when used to treat these conditions.

For chronic pain sufferers that have had persistent pain for three or more months in duration, Medicare will pay for a one or two month trial rental to determine if this device will help or alleviate the chronic pain. You must return to your physician or healthcare provider 30-60 days after your initial evaluation to discuss how the therapy is working and to authorize the purchase of this equipment.

For acute, post-operative pain sufferers, Medicare will consider rental payment for a maximum of 30 days. Any duration longer than that Medicare will deny as not medically necessary.

Your supplier cannot deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.

Therapeutic Shoes

Special therapeutic shoes, inserts and modifications can be covered for diabetic patients with the following foot conditions:

previous amputation of a foot or partial foot

history of foot ulceration or pre-ulcerative calluses

peripheral neuropathy with callus formation

foot deformity

poor circulation in either foot

You must have an office visit with your physician or healthcare provider within six months of receiving new shoes to discuss and document your diabetes management and why you need these special shoes. This office visit must be repeated each time you wish to obtain replacement shoes.

When providing you with shoes, your supplier must perform an in-person evaluation of your foot/feet, and they must verify that your shoes fit properly.

Your supplier cannot deliver this product to you without a written order from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

Urological Supplies

Urinary catheters and external urinary collection devices are covered to drain or collect urine if you have permanent urinary incontinence or permanent urinary retention. Permanent incontinence and retention are defined as a condition that is not expected to be medically or surgically corrected within 3 months.

A maximum of six catheters may be used per day (up to 200 per month), unless it is determined that a higher number is medically necessary by your physician or healthcare provider, and these unique circumstances are specifically documented in your medical records.